POTS Management in General Practice

• Clinical Overview and Treatment Protocol for GPs

• Dr Graham Exelby May 2025

Overview:

Postural Orthostatic Tachycardia Syndrome (POTS) is a form of dysautonomia characterized by excessive heart rate increase on standing without orthostatic hypotension. In the general practice setting, POTS remains under-recognized despite being a significant contributor to fatigue, orthostatic intolerance, and chronic disability in younger populations. This reference outlines a streamlined, evidence-based approach for GPs to diagnose and initiate treatment.

Diagnostic Criteria and Clinical Clues:

Defined as a sustained HR increase ≥30 bpm in adults (≥40 bpm in adolescents) within 10 minutes of standing, without hypotension.- Symptoms must persist for at least 3 months.

Common symptoms: lightheadedness, palpitations, brain fog, fatigue, chest pain, heat intolerance, GI upset, syncope.

• Active standing test (10 minutes upright following 5 minutes supine) is preferred over tilt-table in most settings.

• Exclude secondary causes: anaemia, thyroid disease, volume depletion, adrenal tumours, deconditioning, stimulant medication

First-Line Management: Lifestyle Foundation

• Fluid intake: 2.5–3.0 L per day

• Salt loading: up to 10 g/day if tolerated

• Compression garments: abdomen to ankle preferred

• Recumbent exercise: start with rowing or cycling, progress slowly

• Bed head elevation: 10–15 cm

• Avoid triggers: heat, alcohol, dehydration, high histamine foods

Table 1 Established Therapeutics

a. Heart Rate Inhibitors

b. Vasoconstrictors

c. Sympatholytic medication

d. Blood Volume Expanders

e. Others

IVIG is showing promise in the control of small fibre neuropathy with research from Long COVID.

Adjunctive Diagnostics:

• Supine and Standing ECG: assess QTc, PR interval, HR response (esp. post-COVID)

• Fatigue/sensitization indices: CSI, MSPQ, Bell Disability Scale

• Autonomic testing: NASA Lean Test preferred in fragile phenotypes

Comorbidities to Assess:

• Ehlers-Danlos / hypermobility syndromes

• Mast cell activation (MCAS)

• Migraine, ADHD, Autism, Hashimotos

• Chronic fatigue syndrome (CFS/ME), post-exertional malaise

Multidisciplinary Support Options:

• Physiotherapy (posture, cervical spine mechanics)

• Lymphatic support (manual)

• Dietitian (histamine intolerance, nutrient optimization, avoiding food body sees as a threat)

• Psychologist (pain/fatigue coping, trauma)

• Acupuncture (modulates vagal tone and inflammatory circuits)- Kiiko-Matsumoto style particularly

Patient Communication Principles:

• Validate the illness experience; avoid psychogenic attribution.

• Educate on pacing, heart rate zones, fluid/salt, self-monitoring to establish activity aggravating symptoms

• Encourage consistent rest/activity rhythms; avoid overexertion cycles.

Summary:

POTS requires structured management beginning with non-pharmacologic measures. Pharmacological options should be individualized by phenotype. Recognition of comorbidities and clear communication enhance patient engagement and outcomes. GPs can play a central role in diagnosis and early treatment initiation, improving long-term outcomes.

References:

• Lau et al., Australian Doctor Therapy Update, 2022

• Raj et al., CMAJ, 2022

• Vittone & Exelby, DNA Mutations in POTS and Long COVID, 2024